Im waiting to do a case and considering what pathology I will likely find and how to treat the vascular disease. Practicing in a Metropolitan setting we have a relatively high incidence of diabetes. Although looking at recent increases in the overall incidence of diabetes, every region in the US has a high incidence. We also have a wound care facility staffed by my practice and with that combination we see a lot of major tissue loss.
Our practice pattern has been such that before infrapopliteal options for minimally invasive interventions were available, we performed 20-30 tibial bypasses per month for limb threatening tissue loss. With the accpetance of balloon angioplasty/stenting as a technical option for this region, I have not seen a significan decline in the need to treat severe tibial occlusive disease with open bypass. Especially when it occurs in the face of a large wound which will require excellent, sustained blood flow directly to the region of tissue loss to facilitate healing. Ie, I still believe that pulsatile flow to the area of tissue loss is the gold standard for treatment in this population.
Having said that, there clearly is a role for PTA/Stent or Atherectomy for selected lesions, in selected patients. And when there is short focal disease, we are sometimes able to establish pulsatile flow to the region. However this has been a challenge in a more diffuse pattern of disease. My results with stenting this level have been excellent for immediate technical success, however I am underwhelmed with long term durability as we adhere to a diligent surveillance protocol in addition to our clinical care of the wound.. I tend to tell my residents that the symptoms at presentation, patient co morbidities are just as important as the anatomic findings in dictating what treatment will accomplish our goals for treatment.
All that said, I think that bio absorbable stents represent a possibility for addressing some of the theoretical concerns of mid and long term vessel patency after stenting in the infra popliteal space. Abbot's Absorb stent is promising to this end in some of the preliminary European data.
Here's some information from heart.org
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